She spoke at a health summit event in Falls Church, Virginia, Friday, hosted by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Ritchie is currently chief clinical officer, Department of Mental Health for the District of Columbia.

FIELD CONDITIONS

When women deploy to combat or on exercises, the most discussed topic is whether or not women have the strength and stamina to make it, said Ritchie, who retired in 2010, and served multiple tours in Iraq and Somalia as a psychiatrist, earning three combat patches.

They do have what it takes to make it, she said, adding that women in every war have been in combat. But more often than not, the focus of the women themselves who are deployed is on topics men don't often consider, like sanitation.

Dirty bathrooms are a cause for female urinary tract infections, she said, describing in graphic detail a portable toilet she used during a Team Spirit exercise, in 1980.

"If you get a urinary tract infection, you are not in good physical or psychological health," she said. "They're very painful."

Sanitary conditions today in Afghanistan are often not much better, she said, explaining that she stays in contact with her Army colleagues in the medical community who deploy, and they share with her their experiences.

Another problem related to field latrines is that since some are far from the main living area, the locals or foreign troops sometimes hide out there and assault women, she said.

She said some people might use these examples as evidence that the field and combat are no places for women. However, it doesn't take much effort to clean up the area and properly secure it. If they can build nice dining facilities in Afghanistan, they can certainly get good showers and clean bathrooms.

Managing menstruation in the field is another female concern, she said, related to privacy. There's a true story of a female Soldier during the Gulf War who had nothing but a coffee can in which to change her tampon -- inside a tank with men.

Someone asked Ritchie what a woman was doing inside a tank. She explained that the woman was a medic and they rode in whatever vehicles were available.

When bathrooms are not available, such as during a convoy in the desert, women can use Female Urinary Diversion Devices, she said, explaining that it allows a woman to urinate through a funnel under their uniform. The problem with a FUDD, she said, is women often don't know where to get them and don't know how to use them. Plus, it's emotionally tough to use one in close confines with men around.

Access to birth control isn't always available during a deployment either, she said. Even if having sexual relations is not proscribed by the command in a deployed environment, "people are people." The result can be unplanned pregnancies.

Ritchie touched on other topics such as breastfeeding -- lack of refrigeration to store the milk for women deployed; combat uniforms that don't fit women -- her own helmet flopped around on her head because a smaller size wasn't available; and the stress of leaving small children behind.

All of these concerns aside, Ritchie said women are particularly well suited to combat environments because they are especially "tough and resilient."

In the civilian world, women are at a much higher risk for post-traumatic stress disorder, known as PTSD, than men, she said. In the military, however, that is not the case. In a 2004 study of Service members serving in Iraq and Afghanistan, 12 percent of women had PTSD, and 13 percent of men had it.

"Men are more likely to have deployment-related PTSD, while women are more likely to have sexual assault-related PTSD while deployed," she said.

SEXUAL ASSAULT

The rate of prior sexual assault for women before boot camp "is quite high -- 30 to 45 percent," Ritchie said, much higher than for women going to college.

One of the main reasons: many women enlisting have had difficult backgrounds, including rape and incest, she said. "They want to escape from the environment where these assaults occurred."

In some instances, predatory drill sergeants sense their vulnerabilities and begin probing for opportunities. She explained that probing may begin by touching a shoulder for too long to see how the recruit will react. If she doesn't react, the probing will continue with something slightly more intimate and so on. The drill sergeant might also hint that the recruit might not make it because of body weight or strength issues unless they comply.

These women are far from home, far from their mothers and close friends and they just want to get through boot camp and become Soldiers, she said.

Typically, these women who are raped do not report it. They're embarrassed and want to get on with their lives, she said.

Eventually, someone will report it and when she does, other women step forward. That's the pattern of how these cases usually unfold, said Ritchie, who has been called on a number of times to testify at courts-martial as a subject-matter expert.

These types of incidents don't just happen in boot camp. They are also prevalent in duty stations that are isolated, or in remote areas when deployed, and where control and leadership breaks down, she said, citing Abu Ghraib, Iraq, and a remote area at Aberdeen Proving Ground, Maryland, where illicit sexual acts occurred. In Korea, alcohol and sexual assault are common.

Ritchie compared sexual assaults in remote areas to "Lord of the Flies," a dystopian novel where a group of boys are stuck on an island and rules and discipline break down with dire consequences.

She added that not all incidents occur in remote areas; it's just a more conducive environment where "behavioral drift" can occur.

To prevent sexual assaults, she said commanders and leaders need to know where their troops are and what they're doing at all times, even after normal working hours. They need to look at patterns of when and where assaults occur.

Soldiers who spend an evening on the town need to go with their battle buddies, stay with their battle buddies, and return to the barracks with their battle buddies, she said.

A lot of the advice on sexual assault can apply to men as well, she said, noting that the frequency of male-to-male sexual assault is similar to male-to-female.

Lastly, she said there's not always a clear-cut difference between inappropriate behavior and harassment. In 1980, "a four-star general put his arm around me and said I was his favorite psychiatrist," she said, noting that his arm lingered. She still has mixed feelings on whether she should have reported it or confronted him.

Since that time, the Army and the other services have come a long way with educating Soldiers and leaders about what behaviors are appropriate and which are not, she added.

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